575747

research-article2015
CRE0010.1177/0269215515575747Clinical RehabilitationTunwattanapong et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

The effectiveness of a neck and 2016, Vol. 30(1) 6472

The Author(s) 2015
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DOI: 10.1177/0269215515575747

program among office workers cre.sagepub.com

with neck pain: a randomized

controlled trial

Punjama Tunwattanapong1, Ratcharin Kongkasuwan2

and Vilai Kuptniratsaikul2

Abstract
Objective: To determine the effectiveness of neck and shoulder stretching exercises for relief neck pain
among office workers.
Design: Randomized controlled trial.
Setting: An outpatient setting.
Participants: A total of 96 subjects with moderate-to-severe neck pain (visual analogue score 5/10)
for 3months.
Interventions: All participants received an informative brochure indicating the proper position and
ergonomics to be applied during daily work. The treatment group received the additional instruction to
perform neck and around shoulder stretching exercises two times/day, five days/week during four weeks.
Main outcomes: Pain, neck functions, and quality of life were evaluated at baseline and week 4 using
pain visual analogue scale, Northwick Park Neck Pain Questionnaire, and Short Form-36, respectively.
Results: Both groups had comparable baseline data. All outcomes were improved significantly from
baseline. When compared between groups, the magnitude of improvement was significantly greater in the
treatment group than in the control group (1.4; 95% CI: 2.2, 0.7 for visual analogue scale; 4.8; 95% CI:
9.3, 0.4 for Northwick Park Neck Pain Questionnaire; and 14.0; 95% CI: 7.1, 20.9 for physical dimension
of the Short Form-36). Compared with the patients who performed exercises <3 times/week, those
who exercised 3 times/week yielded significantly greater improvement in neck function and physical
dimension of quality of life scores (p=0.005 and p=0.018, respectively).
Conclusion: A regular stretching exercise program performed for four weeks can decrease neck and
shoulder pain and improve neck function and quality of life for office workers who have chronic moderate-
to-severe neck or shoulder pain.

1Division of Rehabilitation Medicine, Sunprasitthiprasong Corresponding author:

Hospital, Ubonratchatani, Thailand Vilai Kuptniratsaikul, Department of Rehabilitation Medicine,
2Department of Rehabilitation Medicine, Faculty of Medicine Faculty of Medicine Siriraj Hospital, Mahidol University,
Siriraj Hospital, Mahidol University, Bangkok, Thailand 2 Prannok Road, Bangkok 10700, Thailand.
Email: vilai.kup@mahidol.ac.th

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Tunwattanapong et al. 65
Keywords
Neck and shoulder pain, exercise program, office workers, stretching
Received: 4 October 2014; accepted: 8 February 2015
Introduction
Nowadays, desk-based office workers are typically
exposed to prolonged sedentary behavior associ-
ated with computer use. The repetitive strain of the
musculoskeletal system associated with inappro-
priate ergonomic equipment used during daily
work is named work-related musculoskeletal disor-
ders.13 This condition increases the risk of chronic
neck and shoulder pain among office workers.
Moreover, because of its chronic and repetitive
nature, the prevalence of work-related musculo-
skeletal disorders has been increasing rapidly.4
These chronic neck and shoulder pains have
great socioeconomic impact as they are associated
with low work ability and poor quality of life.5
Approximately 56% of sick leave has been attrib-
uted to work-related musculoskeletal disorders.6
Various therapeutic modalities have been used by
patients suffering from work-related musculoskel-
etal disorders; these include exercises, manual
therapy, massage, ergonomics, multidisciplinary
treatment, and energized splint and individual
treatment vs. group therapy.7 Among these, stretch-
ing exercise is our treatment of interest because it
can decrease muscle stiffness by elongating the
elastic component of the musculotendinous unit.8 It
can also decrease pain and improve flexibility.910
In most cases, pain associated with work-related
musculoskeletal disorders causes some degree of
disabilities from limitation of range of motion.
Although a considerable number of studies focus-
ing on the effects of exercise for neck and shoulder
pain in office workers have been conducted, there is
conflicting evidence of the benefits of exercise. For
instance, a Cochrane review in 20074 and 201311
reported the efficacy of conservative interventions
for treating work-related complaints of the arm,
neck, or shoulder in adults. They found that exercise
did not improve pain in comparison with no treat-
ment standardised mean difference (SMD 0.52,
95% confidence interval (CI); 1.08, 0.03), and the
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results were similar for recovery, disability, and sick
leave. However, these evidences were from very
low-quality studies.4,11
Another systematic review performed by
Sihawong etal. recommended either muscle
strengthening or endurance exercise in treating
neck pain for office workers with non-specific
neck pain. Nevertheless, they concluded that fur-
ther high-quality studies are still needed before any
firm conclusion regarding the most effective exer-
cise programs for office workers can be reached.12
Up to now, there are no definite conclusions about
types of exercise for relief of pain and to improve
neck functions in office workers. Our interest is
stretching exercise, owing to its effect in decreasing
muscle stiffness and improving flexibility. Therefore,
this study aimed to determine the effectiveness of a
neck stretching exercise program used in our clinic
on pain reduction and neck function, and quality-
of-life improvements in office workers.
Methods
The present study was a randomized trial per-
formed at the outpatient setting of the Rehabilitation
Medicine Department, Faculty of Medicine Siriraj
Hospital, Mahidol University. The study protocol
was conducted in accordance with the ethical prin-
ciples stated in the most recent version of the
Declaration of Helsinki. After the protocol was
approved by the Institutional Review Board, we
recruited participants by advertising a poster in our
hospital. Anyone interested in participation in the
study was screened by one of our authors, who is a
rehabilitation doctor. The inclusion criteria were
office workers who rated themselves of moderate-
to-severe neck or shoulder pain (visual analogue
scale 5 of 10cm) for more than three months. As
a visual analogue scale 5 represents moderate-
to-severe pain,13,14 we recruited them for treatment.
66 Clinical Rehabilitation 30(1)
The ones who performed regular stretching exer-
cise, had a history of severe neck injury, or neck or
shoulder contracture (defined by a limitation range
of motion in all directions), and a history of neck or
shoulder surgery, or abnormal neurological signs,
were excluded.
Participants, who fitted to the inclusion criteria,
were randomly assigned to either the treatment or
control groups using computer-generated random
numbers. The study codes were placed in sealed
opaque envelops, which were serially opened by
an assistant nurse who was only involved in par-
ticipant enrollment. The demographic characteris-
tics including age, sex, marital status, body mass
index, dominant hand, sitting time/day, computer
using time/day, comorbidities, history of muscle
injury, and regular pain medication, were assessed
at baseline.
All participants received a brochure indicating the
proper position and ergonomics to be applied during
daily work. Only the treatment group was addition-
ally instructed to perform stretching exercises of the
neck and shoulder by one rehabilitation doctor. The
stretching exercise program included 2030 repeti-
tions/session of neck stretching, shoulder stretching,
shoulder rolling, trunk stretching, and back extension
exercises (presented in Appendix, available online),
with a duration of approximately 1015minutes per
session. Two sessions were prescribed per day, five
days a week for a four week duration. Participants
were asked to record the frequency of exercise in a
logbook and bring them to a researcher at the end of
study to ensure the exercise compliance.
Rescue therapy was tramadol (50mg) taken
orally according to patient discretion in case of
intolerable pain, and the number of pills taken was
recorded by each patient. All subjects were asked
to refrain from performing exercises other than the
stretching exercise prescribed and to avoid the use
of pain relief therapy, including pain medication,
physical therapy, massage, or acupuncture.
The outcomes were assessed by one of the coau-
thors (RK) who was unaware of the patients assigned
treatment condition. All participants were not blinded.
The primary outcome was the pain score, measured
using the visual analogue scale.15 The visual analogue
scale ranges from 0 to 10cm, and a higher score indi-
cates more severe pain. The secondary outcomes
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were neck function and quality of life scores. The
neck function was assessed using the Northwick Park
Neck Pain Questionnaire, which measures neck pain
and consequent disabilities. It is composed of 10
questions, with scores ranging from 0 to 36, and were
then transformed into percentages.16 The higher per-
centage represents the severe disability. The quality of
life was evaluated using Short Form-36,17 a question-
naire for the evaluation of health and well-being sta-
tus, which is composed of two main dimensions
(physical and mental). All outcomes were evaluated
at baseline and at the end of the study.
Adverse events were recorded if patients devel-
oped new or deteriorating symptoms during the
study period. The study was stopped if patients
developed serious adverse events, that is, intolerable
pain, or if patients wanted to withdraw from the
study. The compliance with the exercise program in
the treatment group was determined according to the
frequency of exercise reported by the participants.
The sample size was calculated by using nQuery
Advisor program (Statistical Solutions, Cork,
Ireland), based on the pain scores reported in the
study by Savolainen etal.,18 with 5% type I error and
20% type II error. The estimated sample size for each
group was 37 participants. In case of a 30% drop-out
rate, the sample size was calculated at 48 participants
per group. All data were analyzed using SPSS ver-
sion 14. The continuous data were presented in mean
standard deviation (SD), and number (n) and per-
centage (%) for categorical data. Unpaired t-test was
used to compare continuous data and chi-square or
Fishers exact test for categorical data. Mean differ-
ences from baseline scores of visual analogue scale,
Northwick Park Neck Pain Questionnaire score, and
Short Form-36 were compared between groups using
analysis of covariance. A p-value of less than 0.05
was considered statistically significant. The primary
and secondary outcomes were analyzed using both
per protocol and the intention-to-treat population
with last observation carried forward. No interim
analysis was performed.
Results
A total of 118 patients were screened; 22 were
excluded because they presented with a pain score
of less than 5 (16 subjects), refused to participate
Tunwattanapong et al. 67

Assessed for eligibility

(n=118) Excluded (n=22)
Pain score less than 5 (n=16)
Refused to participate (n=5)
Abnormal neurological sign
Randomized (n=1)
(n=96)

Treatment group (n=48) Control group (n=48)

Lost to follow-up (n=7)

Failure of treatment (n=1)

Lost to follow-up (n=2)
Co-intervention (n=1)
Withdrawal (n=1)
Accident (n=1)
Abdominal pain (n=1)
Cancer (n=1)

Inconvenient (n=3)

Completed the study (n=41) Completed the study (n=46)

Figure 1. Disposition of study participants.

(five subjects), or had an abnormal neurological
sign (one subject). As will be seen in the flow dia-
gram (Figure 1), we eventually recruited 96 patients,
of whom 87 completed the trial. Seven participants
in the treatment group and two in the control group
were lost to follow-up. The participant disposition
is detailed in Figure 1. Demographic characteris-
tics, including sex, marital status, dominant hand,
comorbidities, history of muscle injury, and regular
pain medication were presented as a number with
percentages; while others, including age, body mass
index, sitting time/day, computer using time/day,
were presented in mean and standard deviation. All
demographics data were comparable in the treat-
ment and control groups at baseline (Table 1).
Table 2 presents mean and SD of the visual ana-
logue scale, Northwick Park Neck Pain Questionnaire,
and Short Form-36 scores at Week 0 and Week 4,
and mean difference of the scores between the two
groups using the per-protocol analysis. There were
improvements from baseline in all scores for both
groups except Short Form-36 (physical dimension)
of the control group. When compared between
groups, the mean differences of all outcomes
showed significantly different except the mental
dimension of Short Form-36. The magnitudes of
improvements were significantly greater in the
treatment group than in the control group (1.4;
95% CI: 2.2, 0.7 for visual analogue scale; 4.8;
95% CI: 9.3, 0.4 for the Northwick Park Neck

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68 Clinical Rehabilitation 30(1)

Table 1. Baseline demographic characteristics of the study participants.

Control (n=48) Treatment (n=48) p-value

Age (year) 36.5 8.7 34.2 9.0 0.210
Female 43 (89.6) 44 (91.7) 1.000
Marital status
Single 20 (41.6) 27 (56.3) 0.091
Married 24 (50.0) 21 (43.7)
Divorced 4 (8.4)
BMI (kg/M2) 25.5 8.4 23.8 4.7 0.235
Dominant hand: right 46 (95.8) 47 (97.9) 1.000
Sitting time (hour/day) 6.8 1.7 6.9 1.7 0.807
Computer using time (hour/ 5.9 2.1 5.7 1.8 0.574
day)
Comorbidities: n (%) 17 (35.4) 18 (37.5) 0.832
Chronic joint 1 (2.1) 2 (4.2) 1.000
inflammation
Hyperlipidemia 6 (12.5) 4 (8.3) 0.504
Neuromuscular diseases 4 (8.3) 4 (8.3) 1.000
Hypertension 3 (6.3) 2 (4.2) 1.000
Others 8 (16.7) 14 (29.2) 0.225
History of muscle injury
No 39 (81.3) 35 (72.9) 0.622
Regular pain medication 17 (35.4) 15 (31.3) 0.665

Data are expressed as mean SD or number (%). Data were analyzed using unpaired t-test, chi-square test, or Fishers exact test.
BMI: body mass index.

Table 2. Mean, SD of the visual analogue scale pain, Northwick Park Neck Pain Questionnaire, and SF36 score at
Week 0 and Week 4 with mean difference between groups (per-protocol analysis).

Outcomes Study (n=41) Control (n=46) Mean differencea p-value

(95% CI)
Week 0 Week 4 Week 0 Week 4
VAS 6.7 1.2 4.5 1.8 6.2 1.0 5.6 1.8 1.4 (2.2, 0.7) <0.001b
(010)
NPNPQ 28.0 12.1 21.0 10.9 28.2 11.9 25.9 13.9 4.8 (9.3, 0.4) 0.034b
(0100)
SF36
Physical 52.5 19.8 65.3 19.2 62.8 17.9 57.7 19.6 14.0 (7.1, 20.9) <0.001b
Mental 61.6 19.4 70.0 19.6 66.6 18.0 67.9 18.3 5.4 (0.7, 11.6) 0.084
aMean difference between study and control at week 4 adjusted for week 0 using analysis of covariance.
significance at p-value <0.05.
bStatistical

VAS: visual analogue scale; NPNPQ: Northwick Park Neck Pain Questionnaire; SF36: Short Form-36; CI: confidence interval.

Pain Questionnaire score; 14.0; 95% CI: 7.1, 20.9
for physical dimension of Short Form-36).
The analysis using intention-to-treat population
with the last observation carried forward method, pre-
sented in Table 3, showed similar outcomes, except
the Northwick Park Neck Pain Questionnaire score,
which had nearly significant differences (p=0.055).
The magnitudes of improvements were also greater in
the treatment group (1.2; 95% CI: 1.8, 0.5 for
visual analogue scale; 4.1; 95% CI: 8.2, 0.1 for the

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Tunwattanapong et al. 69

Table 3. Mean, SD of the visual analogue scale pain, Northwick Park Neck Pain Questionnaire, and SF36 at
Week 0 and Week 4 with mean difference between groups (intention-to-treat analysis: last observation carried
forward method).

Outcomes Study (n=48) Control (n=48) Mean differencea p-value

(95% CI)
Week 0 Week 4 Week 0 Week 4
VAS (010) 6.6 1.2 4.8 1.8 6.2 1.0 5.6 1.8 1.2 (1.8, 0.5) 0.001b
NPNPQ 28.2 12.0 22.2 11.3 28.9 12.5 26.7 14.5 4.1 (8.2, 0.1) 0.055
(0100)
SF36:
Physical 53.3 19.5 64.3 18.9 61.7 18.5 56.8 19.8 12.9 (6.6, 19.2) <0.001b
Mental 61.6 19.1 68.9 19.5 66.6 18.0 67.9 18.2 4.4 (1.3, 10.1) 0.127
aMean difference between study and control at Week 4 adjusted for Week 0 using analysis of covariance.
significance at p-value <0.05.
bStatistical

VAS: visual analogue scale; NPNPQ: Northwick Park Neck Pain Questionnaire; SF36: Short Form-36; CI: confidence interval.

Table 4. Change scores and mean differences of the visual analogue scale, Northwick Park Neck Pain
Questionnaire, and SF36 in the treatment group according to exercise frequency.

Outcomes Exercise 3 times/week Exercise <3 times/week Mean differencea p-value

(n=31) (n=10) (95%CI)

Week 0 Week 4 Week 0 Week 4

VAS (010) 6.6 1.2 4.3 1.8 6.8 1.4 5.1 1.9 0.7 (1.9, 0.5) 0.264
NPNPQ 28.8 11.4 19.1 8.5 25.5 14.6 27.0 15.3 9.5 (15.9, 3.1) 0.005b
(0100)
SF36:
Physical 51.7 19.1 68.3 17.5 55.1 23.0 55.9 21.9 14.2 (2.6, 25.8) 0.018b
Mental 59.2 18.6 69.1 19.5 68.8 21.1 72.8 20.8 2.6 (9.1, 14.2) 0.659
aMean difference between exercise 3 times/week and exercise <3 times/week groups at Week 4 adjusted for Week 0 using
analysis of covariance.
bStatistical significance at p-value <0.05.

VAS: visual analogue scale; NPNPQ: Northwick Park Neck Pain Questionnaire; SF36: Short Form-36; CI: confidence interval.

Northwick Park Neck Pain Questionnaire score; 12.9;
95% CI: 6.6, 19.2 for physical dimension of Short
Form-36). Three patients in the treatment group and
five in the control group took tramadol (data not
shown). None of the patients reported adverse events
during the study period.
Table 4 shows the effect of frequency of exercise
on the improvement of the visual analogue scale
pain, Northwick Park Neck Pain Questionnaire
score, and quality of life score in the treatment group.
It was found that score improvements of the
Northwick Park Neck Pain Questionnaire and quality
of life scores (physical dimension) were significantly
higher among patients who performed exercise of
3 times/week than among those who performed the
exercises less frequently (p=0.005, mean differences
of 9.5; 95% CI: 15.9, 3.1 and p=0.018, mean dif-
ference of 14.2, 95% CI: 2.6, 25.8, respectively), but
not for the visual analogue scale.
Discussion
Our study demonstrated that stretching exercise tar-
geting the neck and shoulder areas twice/day, five

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70 Clinical Rehabilitation 30(1)
days/week, during four weeks significantly reduced
neck pain and increased neck and shoulder func-
tions among office workers with moderate-
to-severe neck or shoulder pain. Our results were in
line with previous studies showing the benefit of
stretching exercise for this condition. For example,
Irmak and colleagues reported the results of a rand-
omized control trial using a software program that
reminded 39 office workers to perform 10-week
exercises, including strengthening, stretching, and
posture exercise for all body parts.19 Their results
support that exercise reminder software programs
may help to reduce pain among office workers. This
randomized controlled trial was comprised of small
number of subjects, so they suggested that further
long-term studies with more subjects are needed to
describe the effects of these programs.
Another study, performed by Hakkinen etal.,
revealed that manual therapy, twice a week, as well
as stretching exercise five times per week, during
four weeks, was effective for reducing pain in
women with chronic neck pain, but not for improv-
ing neck muscle strength.20 The duration of exer-
cise are similar to our study. Nevertheless, their
study compared stretching exercise with manual
therapy, while ours compared with medical advice,
which was common in our daily practice.
In addition, Blangsted and colleague. reported
that the effect of one-year resistance training of the
neckshoulder region was more effective in reduc-
ing the duration and intensity of neck and shoulder
symptoms than all-around physical exercises.
However, this type of exercise did not improve
work ability or mean sick leave.21 The outcomes
might be explained by the initially high-work abil-
ity (90%) and low mean sick leave (five days per
year) in their study population. Their study was a
long-term study of exercise for one year, using
resistance training, while ours was a four-week
duration of stretching exercise. However, we can
demonstrate the effect of stretching exercise as
early as four weeks of treatment.
Most studies interested in strengthening or resist-
ance exercises, including the study of Anderson
etal,2224 and Zebis etal.25 They emphasized that
strengthening exercises and specific resistance training
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of the shoulder, arm, and hand muscles for office
workers can relieve musculoskeletal pain symptoms
in several regions of the upper body, as well as neck/
shoulder symptoms. However, our interest was the
effect of stretching exercises and we can demon-
strate that stretching exercise can relieve pain,
improve neck functions, and quality of life (physical
dimension of Short Form-36). Therefore, the better
combination should be stretching exercise during an
acute to sub-acute phase of musculoskeletal pain,
followed by strengthening exercise when pain sub-
sides, in order to gain maximal benefits from these
exercises.
Although our study duration was shorter than
those of Irmak etal.19 and Blangsted etal.,21 we
demonstrated the effectiveness of stretching exer-
cises on the improvement of neck and shoulder
pain, and this effect was detected as early as four
weeks of treatment. A previous study, performed
by Weerapong and colleagues, was a before-and-
after study to determine the efficacy of a computer-
ized stretching exercise program for four weeks to
reduce neck and shoulder pain in office workers.26
However, they could not demonstrate the improve-
ment in either the visual analogue scale nor
Northwick Park Neck Pain Questionnaire scores.
This result was caused perhaps by the small sample
size (11 subjects) and very low pain scores at base-
line (1.8 2.1) in their study.
We also found that the frequency of exercise was
directly correlated to the improvement of neck
function scores and physical dimension of quality
of life score, but not for pain score. However, Tsauo
etal. demonstrated the doseresponse effect of
exercise intensity in reducing neck and shoulder
symptoms in sedentary workers.27 Additionally,
Hush and colleagues performed a one-year longitu-
dinal study in office workers and found that those
who exercised more than three times per week
were 1.5 times less likely to develop neck pain
(hazard ratio (HR) 0.64; 95% CI: 0.27, 1.51).28
Another study performed by Korhonen and col-
leagues was a longitudinal study. They found that
office workers who exercised less than two times
per week had 1.4 times greater risk of neck pain
(odd ratio (OR) 1.4; 95% CI: 0.7, 2.7).29
Tunwattanapong et al. 71
As chronic pain has a detrimental effect on
quality of life, pain relief treatment can therefore
improve quality of life. A previous study by Salo
etal. demonstrated the benefit of combined
strength training and stretching group, or stretch-
ing group alone, on quality of life improvement
after a 12-month period.30 However, our study
demonstrated that the improvement of quality of
life could be detected as early as four weeks of
treatment.
There are some limitations in our study. (1) The
length of the observation period. The study should
be repeated with a longer follow-up to confirm the
findings and the longer term effects. (2) The fre-
quency of exercise was self-reported, so patients
may have overstated their compliance of the pre-
scribed program. (3) The small sample size in the
treatment group may preclude conclusions on
doseeffect relationship of exercise. (4) Technique
for dealing with missing data in intention-to-treat
(ITT) analysis should be multiple imputation.
However, we only use the last observation carried
forward technique, which is a bit old fashioned.
(5) Proportion of missing (more patients missing
in the treatment group). However, there was only
one patient missing with the reason of failure of
treatment. (6) Lack of blinding. The interventions
in rehabilitation are difficult to blind. However,
we tried as best to assess the patients with one doc-
tor who was unaware of the patients assigned
treatment condition. (7) The subjective assess-
ments were made from this study. Further studies
should include other objective outcomes.
Clinical message
Stretching exercises of the neck and
shoulder area can reduce pain, and
improve neck function and quality of life
of office workers.
Frequency of exercise 3 times/week
may correlate to the improvement of
neck functions and quality of life.
The effect of stretching exercises could
be detected as early as four weeks of
treatment.
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Acknowledgements
The authors would like to thank the Routine to Research
Project of Siriraj Hospital for providing funding support
for the conduct of this study. The authors would also like
to thank Mr Suthiphol Udompunturak and Ms Julaporn
Pooliam for their assistance with the statistical analysis.
Conflicts of interest
The authors declare no conflicts of interest.
Contributors
PT helped in trial design, allocated participants, and col-
lected the data.
RK performed the literature search and evaluated the
outcomes (blind assessor).
VK designed the clinical trial, analyzed the inter-
preted data, and wrote the manuscript.
Funding
This study was supported by the Routine to Research
Project of Siriraj Hospital.
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Appendix: participant performs all stretching in standing posture

1. Neck stretching

Participant slowly flexes and extends neck, then bend to the left and to the right,

finally, slowly turns the neck to the left and to the right for 5-10 times per

direction.

2. Shoulder stretching

Participant flexes elbow 90 degree bilaterally, swings both arms to the back and

forth for 20-30 times per session.

3. Shoulder rolling

Participant puts hands on shoulders bilaterally, then rolls his/her arm backward in

circular direction for 20-30 times per session.

4. Back extension

Participant puts hands on waists bilaterally, then bends his/her trunk backward

as much as he/she can and returns to the starting posture (stand still with straight

back). Participant repeats 10-20 times per session.

5. Trunk stretching

Participant puts left hand on his/her left waist, then, raises right hand above

head, bends his/her trunk and arm laterally to the left as far as he/she can. Then,

returns to the starting posture, and does with the other side (right). Then,

participant repeats 10-20 times per session.